ASA: Guidelines Urge Same Urgency for TIAs as Stroke

Action Points

Explain to patients who ask that a TIA requires the same careful evaluation and rapid treatment as stroke.

Be aware that TIA increases the risk for recurrent stroke.

Be aware that the guidelines discussed in this article replace earlier guidelines from the American Heart Association.

ORLANDO, Feb. 22 - The American Stroke Association has erased the dividing line that has long separated ischemic stroke and transient ischemic attack (TIA), concluding that the so-called mini-stroke deserves maximum attention.

That is the theme of a new set of guidelines published in the February issue of Stroke, Journal of the American Heart Association, and highlighted at the American Stroke Association International Stroke Conference here.

Patients who survive a TIA or an ischemic stroke face essentially the same unresolved threat, which is the risk of a second--and potentially more severe-cerebrovascular event, said Ralph L. Sacco, M.D., chair of the ASA's Secondary Stroke Prevention Committee and a director of the Stroke and Critical Care Division at New York Presbyterian Hospital.

For that reason, "we are now treating TIA just as a seriously as we treat stroke," he said.

The new guidelines recommend these approaches to risk factor control following an ischemic stroke or a TIA:

Tight control of blood pressure beyond the hyperacute period to reduce the risk of recurrent stroke or other vascular events.

For patients with diabetes, tight glucose control-to near normoglycemic levels to reduce risk of micovascular complications-- as well as control of lipids and blood pressure.

Patients with normal lipid profiles should also be considered for statin therapy to reduce risk of vascular events;

Smoking cessation.

Alcohol consumption should be limited to one to two drinks a day.

Weight reduction should be considered to maintain a BMI between 18.5 and 24.9 kg/m2 and waist circumference of less than 35 inches for women and less than 40 inches for men.

At least 30 minutes of moderate-intensity physical exercise daily.

Recommended interventions for people with extracranial carotid artery disease include:

Carotid endarterectomy for patients with ipsilateral severe or moderate stenosis.

For patients with severe stenosis (more than 70% blockage) who are not good candidates for surgery, carotid artery stenting may be considered.

For patients with an acute MI and a left ventricular mural thrombus, oral anticoagulation is reasonable, aiming for an INR of 2.0 to 3.0 for at least three months and up to one year.

For patients with dilated cardiomyopathy, either Coumadin (INR 2.0 to 3.0) or antiplatelet therapy may be considered for prevention of recurrent events.

For patients with rheumatic mitral-valve disease, regardless of whether atrial fibrillation is present, long-term Coumadin therapy is reasonable, with a target INR of 2.5 (range 2.0 to 3.0)

For patients with mitral-valve prolapse, long-term antiplatelet therapy is reasonable.

For patients with mitral annular calcification, antiplatelet therapy may be considered.

For patients with aortic-valve disease who do not have atrial fibrillation, antiplatelet therapy may be considered.

For patients with modern mechanical prosthetic heart valves, oral anticoagulants are recommended, with an INR target of 3.0 (range 2.5 to 3.5).

Recommendations for antithrombotic therapy for non-cardioembolic stroke or TIA include:

Antiplatelet agents rather than oral anticoagulation to reduce the risk of recurrent stroke and other cardiovascular events. Aspirin (50 to 325 mg/daily), Aggrenox (a combination of aspirin and extended-release dipyridamole), and Plavix (clopidogrel) are all acceptable options for initial therapy.

The combination of Aggrenox is suggested over aspirin alone, and Plavix may be considered over aspirin alone on the basis of direct comparison trials.

The addition of aspirin to Plavix increases the risk of hemorrhage and is not routinely recommended for ischemic stroke or TIA patients.

For patients allergic to aspirin, Plavix is reasonable.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.